Thread: Diplopia for investigation (case 4 July 2007)

History

a 41 year old Indonesian male patient admitted through ER 4 days ago with history of double vision and difficulty in talking for 2 days. Not know to have any medical illness

The problem started with upper respiratory tract infection (for2-3 days) after he came from al-hajj, he took panadol and the symptoms subside then next day in the morning when he woke up he found himself to have a double vision and difficulty in talking.

CNS: There is no loss of consciousness, no tremors, no seizers, no photophobia,
No numbness in the face, no eyelid dropping, no saliva dropping but there is nasal regurgitation just for fluid, no food collection in vestibule of mouth, no dizziness or vertigo, no difficulty in swallowing, no hoarseness in voice, no proximal or distal weakness in upper or lower limbs, he controlled his bowel and the urination, no excessive sweating or dryness,
No neck or back pain.
CVS: no palpitation, no chest pain, no cyanosis,
RESPIRATORY: no dyspnea, or orthopnea, or PND, no cough, no hymoptysis. Just after the admission 2 days he developed epistaxis
GIT: no abdominal pain, no vomiting or hematemesis, no diarrhea or constipation.
SKELETAL: no joints pain or swelling, no bone pain,
HEMATOLOGY: no bruises, no bleeding from any orifices in the body
UROLOGY: no Dysuria, no frequency, no hematuria, no oliguria

This is his 1st admission in a hospital, not know to have any medical illness (HTN, IHD, asthma, DM) -ve past surgical history, never had blood transfusion, no allergy to any medication known.
-ve family history for any medical diseases: No DM, no HTN, no IHD, no asthma. No similar attacks

He is working as a driver for a family; he is married and has 2 children
Not a smoker, no alcohol drinking,



On examination


Patient is conscious, oriented of time and place and person, lying down flat, connected to IV line, he is right handed
Memory intact, patient has nasal speech

CNS examination:
Cranial:
Olfactory: Smell test (not done)
Optic: he has diplopia in all visual field, Pupil reaction minimal and sluggish in light reflex.
3, 4, 6 nerves: there is weakness in eye movements in all directions, there is partial ptosis bilateral
Trigeminal: deep and superficial sensations and motor part are intact
Facial N.: face is symmetrical, wrinkles are intact, no mouth deviation or saliva dropping, nasolabial fold in intact
Acoustic N.: hearing is intact.
9. 10 nerves: he can cough, swallow, uvula in the center, gag reflex intact.
Accessory N.: he can turn his head against resistance to both sides, also he can shrug his shoulder against resistance
Hypoglossal N.: no vasculation or atrophy in the tongue, he can protrude it (central) and move it to both sides, and push it against his check against resistance.


Motor
By inspection: no abnormal posture, no muscle atrophy, or pigmentation, no tremors, no scars (in both lower and upper limbs)
Power 5/5 in upper and lower limbs bilateral
Tone normal also bilaterally in upper and lower limbs
Reflexes: brachioradialis, biceps, triceps reflexes: absent
Knee, ankle reflexes: absent. And plantar reflex is equivocal

Sensory
Intact deep and superficial sensation in both upper and lower limbs

Cerebellar signs:
No nodding of the head, nasal speech (as mentioned above), There is horizontal nystegmus, impaired left nose to finger test, impaired left disdiadokinesia, rebound and drift tests are –ve, no trunkal ataxia.
Gait: wide base gait, Romberg test –ve (not sensory ataxia)

Meningeal signs are -ve

Spine
No spine tenderness on palpation


(Other systems examination, briefly)

CVS: S1 + S2 + 0
RESPIRATORY: bilateral equal air entry, vesicular breathing, no added sounds
GIT: abdomen soft. Lax, no tenderness or masses (neither superficial nor deep)
No lower limb edema


Investigation done for this case:

Vitals checked every 4 hrs
Peak flow rate checked every 4 hrs
U & E (within normal references range)
CBC (within normal reference range)
EMG (unremarkable)
LP (cytology, protein level, glucose level….)
HIV, HCV serology -ve
Chest x-ray: normal
Stool analysis, urine analysis: both are –ve
EEG (unremarkable)
CT brain –ve, repeated with contrast: also –ve
ESR: within normal reference range
MRI: -ve



so whats the diagnosis???

well a very nice case and in well details
possibility of the mysthenia gravis
gullian barrie synndrome
lyme disease
can be placed can u exactly tell me that it is problem in talking or in walking OR SECOND U MENTION ON ONE PLACE NO EYELID DROPING AND ON OTHER PLACE PARTIAL PTOSIS PLZ CLEAR THIS AND WHAT U MEAN BY ABSENT REFLEXES? IN PRESENCE OF WHOLE MOTOR SYSTEM EXAM NORMAL

i can sum up for rapid diagnosis URTI ---> DIPLOPIA PTOSIS AND DIFFCULT WALKING CEREBELLAR SIGN AND ABSENT REFLEXES IN ALL LIMBS .

it is better to write the reflexes in terms of grading ? what u say kats IT IS VERY NICE CASE SO GUYS JUST SHOW RESPONSE DISCUSS IT WARMLY ITS A TIME FOR NEURO!!!

hey is it difficulty in walking or talking or both need to know for a correct answer?

bcas if it difficulty in talking i suggest cavernous sinus thrombosis wats the answer actually?

cavernous sinus can be one of differntial but where u will fit the cerebellar signs >???

There May Be A Possibility Of Mitochondrial Myopathy Which Can Fit In This Patietn As He Returened From Hajj And Now Have Diplopia And Difficult In Walking .

no i dont agree to u if u think so why give details and type of the MM

first of all I am seeing good discussion here:

In neurology the basic thing to do is first localize the lesion>

Let us gather the Positive findings here:

The pt has
1. Opthalmoplegia
2. Central Ataxia
3. Areflexia
4. Mild involvement of Pharyngeal muscles

I wil give u guys some lab findings!

Vitals checked every 4 hrs
Peak flow rate checked every 4 hrs
U & E (within normal references range)
CBC (within normal reference range)
HIV, HCV serology -ve
Chest x-ray: normal
EEG (unremarkable)
CT brain –ve, repeated with contrast: also –ve
ESR: within normal reference range
MRI: -ve
LP *
EMG *
VEP *




CSF :
glucose 2.9 mmol/l
protein 0.50 g/l (<0.45 g/l)
gram stain -ve
culture -ve
wbc 3/cumm normal
Rbc 640/cumm normal (traumatic)
oligoclonal band -ve

(Cytological-protein dissociation)

Electrophysiology :
NCS: motor nerve conduction study was normal
SNAP: absent for median and ulnar nerves

EMG: no evidence for myopathic or neurogenic changes

VEP:
right eye : P100 latency of 123 ms
left eye : P100 latency of 116 ms

Normal (<100)

So there is delay

@ Ali: Myasthenia.. the reflexes wil b normal and the histry wil hav waxing and wanning symptoms..

Miller Fisher syndrome is the correct answer